Adulterants in opioids are the rule: Implications for clinical care


The consideration of adulterants is important in another, emerging problem: Cocaine, colloquially thought of as a drug of the 1980s, is making a comeback. A record amount of cocaine is coming across the Mexican border with increased seizures of drug. Also, the number of acres producing cocaine is increasing, the price per unit sold is decreasing, and the prevalence of use has increased. Unfortunately but predictably, cocaine-related deaths are up: National Vital Statistic Systems data indicate that cocaine-related deaths involving opioids climbed from 2000-2006 and 2012-2015. Opioids, primarily heroin and fentanyl, have been driving the recently reported increases in cocaine-related overdose deaths.6 At the March 12, 2018, Drug Enforcement Administration panel on the reemergence of cocaine and cocaine-related deaths, experts reported that adulterants, including fentanyl, were responsible for many cocaine-related deaths. Strikingly, the most recent data from the state of Florida suggest that fentanyl is found as a factor in nearly all cocaine-related deaths, and cocaine commonly is found in fentanyl and fentanyl analog-related deaths.

Dr. Mark S. Gold, 7th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University, St. Louis. He is chairman of the scientific advisory boards for RiverMend Health.

Dr. Mark S. Gold

If stigmata of opioid overdose (for example, miotic pupils and respiratory depression) are present in a patient considered to have overdosed on cocaine, naloxone should be administered, as the clinical presentation may be tied to the presence of opioid adulterants. Then, the patient should be engaged in treatment in a long-term care model with evidenced-based therapies, including medication-assisted treatment and contingency management. An important point, however, as described by Thomas Kosten, MD, professor of psychiatry at Baylor University, Houston, is that while we have multiple pharmacologic treatments for opioid overdose and addiction, none exist for cocaine overdose, craving, addiction, or withdrawal.7 Dr. Kosten has pioneered novel treatments for cocaine addiction, including anti-cocaine vaccines, but none has been proven safe and effective as of 2018.

Dr. A. Benjamin Srivastava, a fourth-year resident in the department of psychiatry at Washington University, St. Louis

Dr. A. Benjamin Srivastava

Indeed, in the context of the opioid epidemic, the demand for opioid use treatment has increased, though the consequences of addiction, and thus areas requiring treatment in the opioid-addicted patient, are high in number and complexity.8 As we discussed previously, unfortunately, most management is aimed solely at reversing the overdose, stabilizing the patient medically, and discharge. We suggest that prior to discharge, the physician should determine whether the overdose was accidental, a suicide9 attempt, passive suicidality (for example, asking “Would you be better off dead?”),10 extreme risk-taking behavior (akin to playing Russian roulette,11 or other causes. We have suggested that naloxone is similar to cardiopulmonary resuscitation: It is a critical life-saving intervention but not an end in itself. Rather, the need for naloxone should serve as a gateway to comprehensive evaluation, diagnosis, treatment, and long-term care.

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